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1801 Hickman Road
Des Moines, IA 50314-1597
(515) 282-2200
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Student Application
General Information
First Name
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Address 1
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Home Phone
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Desired Status:
Job Shadow (4–8 hours only)
Clinical Preceptor
Clinical Group
Date Available
*
FOR
JOB SHADOW
APPLICANTS ONLY
— Time Availablilty Preference
Morning Hours (e.g. 8–12)
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Tuesday
Wednesday
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Friday
Afternoon Hours (e.g. 12–5)
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Program
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Instructor Phone
Educational Level Currently Enrolled (select one)
High School Diploma
Certificate
Diploma — Nursing
12-Month Post-Baccalaureate
Post-Master's Certificate
Resident
Post-Graduate
Doctor of Dental Surgery (D.D.S., D.M.D.)
Doctor of Psychology (PsyD)
Other
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Doctor of Public Health (DrPH)
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Faculty Member
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Doctor of Veterinary Medicine (D.V.M.)
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Adult Learner
Educational Level Currently Enrolled (select one)
Allopathic Medicine (M.D.)
Chiropractor
Clinical Lab Worker
Clinical Psychology
Community Health Worker
Dental Hygienist
Dietitian/Nutritionist
EMT/Paramedic/First Responder
General Dentistry
Health Education/Behavior Spec
Health Information/Data Analyst
Health Services/Hospital Admin.
Nurse (LPN/LVN)
Nurse (RN)
Nurse Midwife
Nurse Practitioner
Occupational Therapy
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Podiatrist
Psychiatrist
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Emergency Information
Do you have medical limitations or conditions the hospital should be aware of in the event that you ever have a medical emergency while there?
Yes
No
If yes, please describe:
In case of emergency we should contact:
Name
Relationship
Phone
Alternate Contact:
Name
Relationship
Phone
Background Information
Do you have a record of child or dependent adult abuse?
Yes
No
If yes, please describe:
Have you ever been convicted of a crime in Iowa or in another state or country?
Yes
No
If yes, please describe:
Next
Signature
Release of Liability
I hereby agree that while I am participating in any education experience, Broadlawns Medical Center will not be held responsible for any injury or accident that might occur. Any medical expenses incurred as a result of such injury or accident will be my responsibility.
Name:
Date:
Release of Information
I give my education facility permission to release my medical history as needed by Broadlawns Medical Center for auditing and regulatory purposes.
Name:
Date:
Agreement
I agree to the following requirements, with the understanding they may be required for my internship/clinical rotation/job shadow experience at Broadlawns Medical Center*:
Turberculosis (TB) skin test within last 4 years.
MMR tier or proof of immunization - 2 doses.
Physical exam within the last 4 years. Not required for job shadowing.
Criminal background check.
Wear school or student identification badge at all times during internship/clinical rotation/job shadow experience.
*If you do not have one of these requirements, please contact Kari Ford at (515)282-2278 or Dianna Peterson at (515)282-2483.
I understand my responsibility to be on time, attentive, courteous, and protective of patient confidentiality.
I understand that in the performance of my duties as a student, I must hold in strictest confidence any observations I may make or hear regarding patients, patient families, clients, staff, or volunteers.
I understand that intentional or involuntary violation of confidentiality may result in disciplinary action, including termination of my own internship/clinical rotation/job shadow experience and/or possible legal action by others (i.e. patients, patient families, clients, staff, etc.).
Name:
Date:
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